TRINIDAD AND TOBAGO ORS CASE STUDY

UNIVERSITY OF WASHINGTON GLOBAL HEALTH START PROGRAM REQUEST FROM BILL & MELINDA GATES FOUNDATION AUTHORS: EMILY MOSITES, ROB HACKLEMAN, KRISTOFFER L....
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UNIVERSITY OF WASHINGTON GLOBAL HEALTH START PROGRAM REQUEST FROM BILL & MELINDA GATES FOUNDATION AUTHORS: EMILY MOSITES, ROB HACKLEMAN, KRISTOFFER L.M. WEUM, JILLIAN PINTYE, LISA E. MANHART, AND STEPHEN E. HAWES NOVEMBER 2012

TRINIDAD AND TOBAGO ORS CASE STUDY

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Acknowledgements We greatly appreciate the input on these case studies from several key informants, thought partners and reviewers from multiple organizations involved in the promotion of ORS and zinc. The Bill & Melinda Gates Foundation and UW START would like to thank the following individuals for their contribution to this case study: Robert Clay, USAID Christopher Behrens, I-TECH Dr. Natalie Dick, Pediatrician Dr. David Bratt, Pediatrician Dr. Yvette Holder, PAHO/WHO Dr. Merle Lewis, PAHO /WHO Evan Simpson, PATH Dan Carucci, McCann Health

Disclaimer Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and Skye Gilbert, Saul Morris, and Shelby Wilson of the Bill & Melinda Gates Foundation and do not necessarily reflect the views of the key informants, thought partners or reviewers.

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OVERVIEW Status: Major players: Financing: Price: Regulatory change:

Unsustained Success David Bratt, MoH, IDRC IDRC, MoH Free in public sector None required

FIGURE 1: KEY FEATURES OF TRINIDAD AND TOBAGO ORS SCALE-UP

Trinidad and Tobago scaled-up Oral Rehydration Therapy (ORT) in the early 1980s as economic prosperity was growing in the country. Nevertheless, the country has been classified as an unsustained success in the scale-up of ORS for the treatment of diarrheal disease. In 1987 the Trinidad and Tobago Demographic and Health Survey (DHS) reported that 53% of children with diarrhea were treated with ORS (DHS 1987). However, in a World Bank Study in 2006, ORS was used to treat only 32% of children under 5 years of age with diarrhea in Trinidad and Tobago (World Bank 2010). This figure represents a substantial decline in ORS use compared to the DHS estimate from the late 1980s. The short scale-up campaign was largely driven by a single physician who observed crowded gastrointestinal wards at the regional hospitals (Figure 1). The small islands had a strong health care infrastructure in place and the targeted population was easily reached with a small budgeted marketing campaign. Since the scale-up, the country has improved its sanitation and water quality, which has led to a substantial reduction in both the incidence of and attention paid to diarrheal disease. TABLE 1: KEY CONTEXTUAL INFORMATION ABOUT TRINIDAD AND TOBAGO

Statistic Total population Under 5 population Under 5 mortality rate HDI ranking GNI per capita Life expectancy

Estimate 1.3 M 39 K 35 / 1,000 live births 62 / 187 countries $23,439 70.1 years

Source (UNDESA 2011) (MICS 2006) (UNDESA 2011) (UNDP 2011) (UNDP 2011) (UNDP 2011)

CONTEXT The Republic of Trinidad and Tobago has abundant oil and gas reserves and a relatively small population of 1.3 million inhabitants, giving the country one of the highest per capita incomes in the Caribbean. Export of petroleum began in the 1950s, and the twin-island nation saw a doubling of its GDP during the global oil production shortages in the 1970s. The period of high economic growth lasted from 1974 to 1982, and was followed by a long period of negative growth per capita (1983-1993), caused by the fall in the international price of oil and in domestic oil production. The negative growth trend reversed in later years and in current US dollars, per capita GDP increased from $4,000 in 1990 to over $15,000 in 2010 (Artana, Auguste et al. 2008, Moya, Mohammed et al. 2010). Access to an improved source of drinking water increased from 40% to 96% of the population between the 1980s and 2006, and 99% of the population had access to sanitary means of waste disposal as of 2006 (UNICEF 2008). Despite this strong

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growth in development, Trinidad and Tobago is also vulnerable to natural disasters such as droughts, floods and earthquakes, which potentially result in diarrheal disease outbreaks (UNDP 2012). DEMOGRAPHICS

In 2010, Trinidad and Tobago had a population of 1.3 million (Table 1), growing at a meager annual rate of less than 1% since the mid-1980s. Approximately equal parts (40%) of the population have either Asian-Indian or African heritage. The remaining 20% includes European, Chinese, Middle-Eastern, and Amerindian ancestry. Only 14% of the population lived in urban areas in 2010, and the three largest cities are Chaguanas (pop. 67,000), San Fernando (pop. 55,000), and the capitol, Port of Spain (pop. 49,000). English is the official language of Trinidad and Tobago, but most people speak a Creole dialect that incorporates African and Spanish heritage (World Bank 2010). HEALTH CARE SYSTEM

Trinidad and Tobago has both public and private health care providers, all regulated by the Ministry of Health (MoH), which also sets prices. The MoH operates through five Regional Health Authorities (RHAs). The MoH sets guidelines that are implemented by the RHAs with funding provided by the MoH. The RHAs also inspect health facilities to ensure compliance with directives. Public health care is free in Trinidad and Tobago. There are 9 hospitals, 9 District Health Facilities and 96 health centers (Ministry of Health 2012). The MoH reported diabetes, heart disease, and cancer as the major health challenges faced by the country in its annual report in 2005 (Ministry of Health 2005). According to the 2006 Multiple Indicator Cluster Survey (MICS), between 1996 and 2006 infant mortality increased from 15 to 29 per 1000 and under-5 mortality increased from 15 to 35 per 1000 (UNICEF 2008). This increase appears to be due to an increase in the rate of premature birth and birth defects (PAHO/WHO 2008). UNICEF reports that diarrhea accounted for less than 1% of deaths of children under 5 years of age in Trinidad and Tobago (UNICEF 2008). OTHER META-TRENDS

Global oil prices experienced a prolonged decline in the 1980s, leading to a decline in the islands’ prosperity. Financial turbulence, as well as mistrust between residents of African and Asian-Indian descent (the latter dominating government and professional roles) led to street rioting and claims of widespread corruption in government and public services. Trinidad and Tobago’s position as a transit point for cocaine trade also fueled the emergence of drug-related gang violence. Since 2000, the country has experienced considerable economic fluctuation. Development of the financial sector and large increases in natural gas exports resulted in six years of double-digit annual GDP growth, followed by a 27% one-year drop in GDP concurrent with the global financial crisis of 2008-2009 (World Bank 2010).

HEALTH SYSTEM SUCCESSES AND IMPLEMENTATION Trinidad and Tobago has good public sanitation; a 2006 survey found that 96% of the population uses an improved source of drinking water and 72% have water piped into their dwelling. This represents a substantial increase from 1980, when only 40% of households had water piped in. Ninety-nine percent of residents use sanitary means of waste disposal; 65% and 19% had flush toilets piped to a septic tank and sewer system respectively, while 13% used a pit latrine with a slab cover (UNICEF 2008).

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100% 90% 80% 70% 60% 50% 40%

DTP3 immunization coverage among 1-year-olds Women 15-45 using modern contraceptives Children

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